24-h pH Research Articles

Predictors of reflux aspiration and laryngo-pharyngeal reflux.

Gastro-esophageal reflux disease (GERD) can present with typical or atypical or laryngo-pharyngeal reflux (LPR) symptoms. Pulmonary aspiration of gastric refluxate is one of the most serious variants of reflux disease as its complications are difficult to diagnose and treat. The aim of this study was to establish predictors of pulmonary aspiration and LPR symptoms. Records of 361 consecutive patient from a prospectively populated database were analyzed. Patients were categorized by symptom profile as predominantly LPR or GERD (98 GER and 263 LPR). Presenting symptom profile, pH studies, esophageal manometry and scintigraphy and the relationships were analyzed. Severe esophageal dysmotility was significantly more common in the LPR group (p = 0.037). Severe esophageal dysmotility was strongly associated with isotope aspiration in all patients (p = 0.001). Pulmonary aspiration on scintigraphy was present in 24% of patients. Significant correlation was established between total proximal acid on 24-h pH monitoring and isotope aspiration in both groups (p < 0.01). Rising pharyngeal curves on scintigraphy were the strongest predictors of isotope aspiration (p < 0.01). Severe esophageal dysmotility correlates with LPR symptoms and reflux aspiration in LPR and GERD. Abnormal proximal acid score on 24-h pH monitoring associated with pulmonary aspiration in reflux patients. Pharyngeal contamination on scintigraphy was the strongest predictor of pulmonary aspiration.

Comparison of Reflux Symptom Index (RSI) with Reflux Finding Score (RFS) and Its Effectiveness in Diagnosis of Laryngopharyngeal Reflux Disease (LPRD).

LPRD is a common condition in patients attending ENT OPDs. Although esophageal manometry and 24h pH monitoring is considered the gold standard for diagnosis, it is an expensive and time consuming investigation. Newer clinical scales have been developed for diagnosing LPR such as RSI, RFS, Carlsson-Dent, ReQuest, GerdQ, etc. The objective of the study is to compare RSI with RFS and to establish its effectiveness in diagnosing LPRD among OPD patients. It's a descriptive cross-sectional study. ENT outpatients with features of LPRD were asked to fill RSI proforma (score ≥ 13 abnormal), after which they were subjected to indirect laryngoscopy to obtain the RFS (score ≥ 7 diagnostic of LPRD). RSI was compared with RFS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of RSI were noted. Of 165 patients, 53.9% were females. Mean RSI scores in males and females were 11.9 and 11.5 and mean RFS scores were 6.4 and 5.7 respectively. RSI had 79.1% sensitivity and 83.7% specificity in diagnosing LPRD with PPV 76.8%, NPV 85.4% and accuracy 81.8% (Chi square value 64.5, p ≤ 0.01). There was substantial agreement between RSI and RFS (Cohen's kappa: 0.625, p ≤ 0.0001). RSI is a simple tool to diagnose LPRD which doesn't mandate invasive procedures such as endoscopy or esophageal manometry. Hence it can be used effectively to diagnose LPRD in ENT outpatients and start the treatment at the earliest.

Hypotonic Low Esophageal Sphincter Is Not Predictive of Gastroesophageal Reflux Disease After Sleeve Gastrectomy.

Sleeve gastrectomy is the most commonly performed bariatric surgery these days but is associated with de novo reflux. We aimed to study the influence of hypotonic lower esophageal sphincter (LES) on postoperative gastroesophageal reflux disease (GERD). Patients with pre- and postoperative esophageal high-resolution manometry (HRM) and 24-h pH monitoring (pHM) were included retrospectively in our study. Preoperative hypotonic LES was defined by a mean residual pressure of the lower esophageal sphincter < 4mmHg. Postoperative GERD was defined by a DeMeester's score > 14.72. We also evaluated postoperative manometric changes at the esophageal-gastric junction. Sixty-nine patients (54 females and 15 males) had pre- and postoperative HRM and pHM. The mean age was 45.9 ± 9.8years. The mean body mass index (BMI) was 47.5 ± 7.5kg/m2. Hypotonic LES concerned 21 patients (30.4%) before sleeve gastrectomy. The mean time between the two esophageal monitorings was 32.1 ± 24.1months. The sensitivity, specificity, positive predictive value, and negative predictive value of hypotonic LES to predict GERD were 31, 70, 52, and 48% respectively. The LES minimal residual pressure was not statistically decreased after sleeve gastrectomy (p= 0.24). Only the wave speed, esophageal length, and LES length were significantly reduced after SG (p = 0.029, 3.8 × 10-7 and 0.00032). Hypotonic LES has a poor predictive value on postoperative GERD. The LES's length is significantly reduced after SG and this could be a factor explaining de novo reflux.

Predictive Factors of Gastroesophageal Reflux Disease in Bariatric Surgery: a Controlled Trial Comparing Sleeve Gastrectomy with Gastric Bypass.

To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity. Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery. Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m2): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m2 vs. 42.7 ± 5.7 kg/m2; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78-40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9-52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6-44.8), and age (OR 2.0, 95%CI 1.1-3.4). One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.

Rumination Syndrome: Recognition and Treatment.

The purpose of this paper is to discuss current diagnostic and treatments of rumination. Rumination is often underdiagnosed or misdiagnosed in adults, especially when symptoms suggest regurgitation rather than vomiting accompanied by re-chewing and re-swallowing and should be included in the differential diagnosis. It is primarily diagnosed clinically by ROME-IV or DSM-5. That rumination can be re-affirmed by characteristic patterns on objective testing such as high-resolution esophageal manometry and 24-h pH impedance testing. However, although gastroduodenal manometry and EMG are helpful, these tests are slowly losing interest given their technical nature of data gathering, time consumption, cost burden, and patient discomfort. Rumination is primarily diagnosed clinically by ROME-IV or DSM-5 in addition to high-resolution esophageal manometry and 24-h pH impedance. Management is challenging and usually a combination of behavioral, pharmacological, and rarely surgical treatment. Recent data demonstrate that the combination of behavioral techniques such as diaphragmatic breathing exercises and/or with baclofen has promising results. Further research is necessary to further define objective criteria for diagnosis and other therapeutic modalities for treatment.

Transient Lower Esophageal Sphincter Relaxations and Mechanical Incompetence of the Lower Esophageal Sphincter – Is There a Relationship?

Introduction: The detailed process of a gastroesophageal reflux event is still under controversial discussion. Gastroenterologists have developed and favor the concept of Transient Lower esophageal Sphincter Relaxations (TLESR`s) as the major cause of gastroesophageal reflux episodes. TLESR`s are related with reflux episodes both in healthy individuals and patients with GERD. Another concept around the functional mechanism of the antirefluxbarrier is a more mechanical interpretation of the Lower Esophageal Sphincter (LES), developed by surgeons. The aim of this study is to investigate this relationship between TLESR`s and the mechanical failure of the LES by investigating these criteria in the same individuals. Methods: In a referral center for esophageal and gastric functional disease at the University Hospital in Würzburg, Germany, we investigated healthy volunteers and patients with proven GERD. The assessment of the LES consisted of the overall length, the intraabdominal length, and the end-expiratory pressure of the LES. The manometry was performed in a station-to-station-pull-through technique. The changing LES pressure and the TLESRs were measured with a sleeve catheter according to the protocol published by Dent and Schoeman. The presence of pathologic reflux in patients was evaluated by 24h pH monitoring. Results: In total, 8 healthy volunteers were investigated (median age: 26 years (22-34)). In addition, 21 patients with GERD were evaluated (median age: 49 years (25-68)). The frequency of TLESR´s was quite low in volunteers and patients with 0,4 TLESR`s/h and 0,6 TLESR`s/h respectively. While the frequency of TLESR`s was not different between volunteers and GERD-patients, the percentage of reflux-associated TLESR`s was significantly higher in GERD-patients with mechanically incompetent LES (20,8%), compared to the percentage in GERD-patients with intact LES (6,8%) and also compared to the percentage in healthy volunteers (7,8%) (p<0,001). Conclusion: The present analysis shows a relationship between a mechanically incompetent LES and an increased number of reflux-associated TLESR`s, suggesting that the two mechanisms are not mutually exclusive, but may be instead different measurements of the same condition - a functionally and mechanically defective LES.

PSIX-22 Effects of betaine supplementation on growth performance, muscle amino acid contents, meat quality and antioxidant capacity in finishing pigs

Abstract The aim of this study was to investigate the effects of betaine supplementation on growth performance, muscle amino acid contents, meat quality and antioxidant capacity in finishing pigs. A total of 144 crossbred barrows (Duroc×Landrace×Yorkshire) weighing about 69 kg were divided into three groups with six replicates of eight pigs each for a 60-day feeding trial. Pigs were fed a maize-soybean meal basal diet supplemented with 0 (control), 1 or 1.5 g/kg betaine, respectively. Data were analyzed by one-way ANOVA using SPSS software, and the differences among treatments were examined by Tukey’s test, which were considered to be significant at P &amp;lt; 0.05. The results showed that the feed conversion ratio tended to be improved (P = 0.081) by betaine supplementation. Compared with the control, 1.5 g/kg betaine supplementation significantly increased (P &amp;lt; 0.05) the contents of methionine, glutamate and total non-essential amino acid in thigh muscle, but the amino acid contents in loin muscle were not affected by betaine supplementation. The 24-h and 48-h drip loss of thigh muscle and the content of malondialdehyde in loin muscle were decreased (P &amp;lt; 0.05) by 1 g/kg betaine inclusion, and the 24-h redness values of loin and thigh muscles were increased (P &amp;lt; 0.05) by 1.5 g/kg betaine inclusion. Moreover, both levels of betaine significantly increased (P &amp;lt; 0.05) 24-h pH value and the activity of total superoxide dismutase of loin and thigh muscles. Overall, this study indicated that 1.5 g/kg betaine supplementation could increase the contents of methionine, glutamate and total non-essential amino acid in thigh muscle rather than loin muscle, and betaine supplementation was beneficial to improve meat quality and antioxidant capacity in finishing pigs. 1SEM, total standard error of means (n = 6)

Pathological Implications of Swallow-Associated Transient Lower Esophageal Sphincter Elevation

BackgroundThe lower esophageal sphincter (LES) overlaps the crural diaphragm (CD) in patients without hiatal hernia (HH). Swallowing induces esophageal peristalsis with longitudinal esophageal shortening, causing transient elevation of the LES above the CD. This phenomenon, visible on high-resolution manometry (HRM), is called swallow-induced transient HH (tHH). MethodsWe assessed pathological implications of swallow-induced LES elevation. We included patients who underwent 24-h pH monitoring and HRM between January 1, 2017 and June 30, 2018. Patients with manometric HH were excluded. Patients were divided into 3 groups: persistent tHH, which indicated significant LES–CD separation (i.e., ≥ 1cm in ≥ 30% swallows, or ≥ 2cm in ≥ 10% swallows) at the second inspiration after the conclusion of swallow-induced esophageal peristalsis; incidental tHH, which indicated significant LES–CD separation at the first inspiration after peristalsis without meeting persistent tHH criterion; and non-tHH. ResultsIn total, 107 patients were included. There were 18 patients in the persistent tHH group, 54 in the incidental tHH group, and 35 in the non-tHH group. No differences were observed in esophageal body motility or LES antireflux barrier parameters among groups. However, patients with persistent tHH had significantly higher DeMeester scores, longer acid exposure time, and poorer acid clearance. Prevalence of pathological reflux was 83.3% in the persistent tHH cohort. Esophagogastroduodenoscopy showed that 76.9% of patients with persistent tHH had no HH. Endoscopic findings of the esophagogastric junction were similar among groups. ConclusionsPersistent tHH seems to be a pathological finding associated with pathological reflux.

Long-term high-grain diet altered the ruminal pH, fermentation, and composition and functions of the rumen bacterial community, leading to enhanced lactic acid production in Japanese Black beef cattle during fattening.

To increase intramuscular fat accumulation, Japanese Black cattle are commonly fed a high-grain diet from 10 to 30 months of age although it can result in the abnormal accumulation of organic acids in the rumen. We explored the effect of long-term high-concentrate diet feeding on ruminal pH and fermentation, and its effect on the rumen bacterial community in Japanese Black beef cattle during a 20-month fattening period. Nine castrated and fistulated Japanese Black beef cattle were housed with free access to food and water throughout the study period (10-30 months of age). The fattening stages included Early, Middle, and Late stages (10-14, 15-22, and 23-30 months of age, respectively). Cattle were fed high-concentrate diets for the experimental cattle during fattening. The body weight of the cattle was 439 ± 7.6, 561 ± 11.6, and 712 ± 18.5 kg (mean ± SE) during the Early, Middle, and Late stages, respectively. Ruminal pH was measured continuously during the final 7 days of each stage, and rumen fluid and blood samples were collected on day 4 (fourth day during the final 7 days of the pH measurements). The 24-h mean ruminal pH during the Late stage was significantly lower than that during the Early stage. Total volatile fatty acid (VFA) during the Late stage was significantly lower than during the Early and Middle stages, but no changes were noted in individual VFA components. The lactic acid concentration during the Late stage was significantly higher than that during the Early and Middle stages. The bacterial richness indices decreased significantly during the Late stage in accordance with the 24-h mean ruminal pH. Among the 35 bacterial operational taxonomic units (OTUs) shared by all samples, the relative abundances of OTU8 (Family Ruminococcaceae) and OTU26 (Genus Butyrivibrio) were positively correlated with the 24-h mean ruminal pH. Total VFA concentration was negatively correlated with OTU167 (Genus Intestinimonas), and lactic acid concentration was correlated positively with OTU167 and OTU238 (Family Lachnospiraceae). These results suggested that long-term high-grain diet feeding gradually lowers ruminal pH and total VFA production during the Late fattening stage. However, the ruminal bacterial community adapted to feeding management and the lower pH during the Late stage by preserving their diversity or altering their richness, composition, and function, to enhance lactic acid production in Japanese Black beef cattle.

Clinical outcomes of gastroesophageal reflux disease-related chronic cough following antireflux fundoplication.

Despite the effectiveness of antireflux fundoplication for typical gastroesophageal reflux disease, outcomes regarding surgical therapy for patients with gastroesophageal reflux disease-related chronic cough are currently unclear. The purpose of this study was to evaluate whether antireflux surgery for patients with chronic cough is effective, and to assess the correlation between indexes, such as symptom index and symptom association probability, and response to surgery. We performed a retrospective review of a prospectively collected database from a 3-site institution from 2013 to 2017. Of 1149 patients who underwent antireflux surgery, 41 presented with chronic cough as a main symptom related to gastroesophageal reflux disease. Preoperatively, patients underwent a symptom assessment, esophagogastroduodenoscopy, esophageal 24-h pH monitoring, and manometry. Patients were followed up at 6weeks and 12months post-surgery. Thirty-three (80.5%) patients underwent Nissen fundoplication, while 8 (19.5%) underwent Toupet fundoplication. Isolated chronic cough was present in 8 (19.5%) patients, and median (range) DeMeester score was 28.9 (0.3-96.7). After 12-month follow-up, chronic cough was absent in 28 (68.3%) patients (P = .02). Typical reflux symptoms responded well to surgery, but response was not optimal. Postoperative dysphagia and atypical reflux symptoms were slightly worse on long-term follow-up; however, differences were not significant (P ≥ .2). When examining how the different symptom indexes correlated with complete, partial, or no response in patients with gastroesophageal reflux disease-related cough, there was no notable agreement on predicted response to surgery. Antireflux surgery, although less predictable, is effective for the treatment of gastroesophageal reflux disease-related chronic cough.

Idiopathic calcium nephrolithiasis with pure calcium oxalate composition: clinical correlates of the calcium oxalate dihydrate/monohydrate (COD/COM) stone ratio.

Pure calcium oxalate is the most frequent type of idiopathic kidney stone composition. Fourier transform infrared spectroscopy (FT-IR) allows to detect the ratio of calcium oxalate dihydrate (COD) and monohydrate (COM) crystals in stones, but the clinical significance of this parameter remains uncertain. The objective of this observational study was to verify the association of clinical and laboratory parameters of kidney stone disease with COD/COM ratio in a group of 465 (322M, age 46 ± 14) patients suffering from idiopathic calcium nephrolithiasis with pure calcium oxalate stones (≥ 97%). Each participant underwent a complete clinical examination, serum chemistry, 24-h urine collection for the determination of the profile of lithogenic risk, and had stones analyzed by FT-IR. Most (62%) of the stones had a COD/COM ratio ≤ 0.25, and the urine chemistry of the corresponding patients showed a low prevalence of urinary metabolic abnormalities. With increasing COD/COM ratio intervals (0-0.25, 0.26-0.50, 0.51-0.75, 0.76-1), a significant association was observed for the number of urological procedures, serum calcium, 24-h urinary calcium excretion, prevalence of hypercalciuria and relative calcium oxalate supersaturation, and a negative trend was detected for the age of the first stone episode (all p values < 0.05). A linear regression model showed that the only parameters significantly associated with COD/COM ratio were 24-h urinary calcium excretion (standardized β = 0.464, p < 0.001) and urine pH (standardized β = 0.103, p = 0.013). In pure calcium oxalate idiopathic stones, COD/COM ratio may reflect the presence of urinary metabolic risk factors, and represent a guide for the prescription of urinary analyses.

Endoscopic Variceal Sequential Ligation Does Not Increase Risk of Gastroesophageal Reflux Disease in Cirrhosis Patients

BackgroundEndoscopic variceal sequential ligation (EVSL) is currently endorsed in our hospital, as the preferred endoscopic treatment for prevention of variceal rebleeding and achieving adequate hemostasis. There is currently a lack of consensus surrounding EVSL-induced changes in esophageal motor function and abnormal reflux.AimsTo explore alterations in esophageal motor function and risk of abnormal gastroesophageal reflux in liver cirrhosis patients with esophageal varices, after EVSL.MethodsTwenty-one liver cirrhosis patients with esophageal varices were studied using manometry and 24-h pH monitoring 1 day prior to and 1 month following EVSL. The EVSL consisted of performing esophageal variceal ligation using a multi-band ligator, which was repeated every 4 weeks until the varices were eradicated.ResultsThe amplitude and duration of peristaltic contraction waves and the percentage of abnormal esophageal contraction waveforms were unaltered in both the proximal (P > 0.05) and the distal (P > 0.05) esophagus after EVSL. However, the lower esophageal sphincter pressure was decreased following EVSL (16.1 ± 7.9 mmHg vs 21.1 ± 6.3 mmHg (P < 0.05)). Various quantitative parameters including percentage of total monitoring time with pH < 4.0, total number of reflux episodes, number of reflux episodes > 5 min, and DeMeester scores were not increased in post-EVSL patients. Abnormal reflux monitored by 24-h pH monitoring occurred in ten (47.6%) pre-EVSL patients and 11 (52.4%) post-EVSL patients.ConclusionsAlthough EVSL affects esophageal motility by relatively decreasing LES pressure, it does not induce substantial motor abnormalities nor increase risk of abnormal gastroesophageal reflux disease in cirrhosis patients.

The impact of cervical lymph node dissection on acid and duodenogastroesophageal reflux after intrathoracic esophagogastrostomy following transthoracic esophagectomy.

The aim of this study was to evaluate the impact of cervical lymph node dissection on acid reflux and duodenogastroesophageal reflux (DGER) in patients undergoing transthoracic esophagectomy with gastric tube reconstruction and intrathoracic esophagogastrostomy. Thirty-one patients receiving transthoracic esophagectomy with gastric tube reconstruction by intrathoracic esophagogastrostomy were divided into the following two groups: a two-field lymph node dissection group (2F group) and a three-field lymph node dissection group (3F group). All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy at 1year after surgery. The 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were compared between the 2 groups. No acid reflux was observed in the 2F group, whereas it was observed in 6 (40%) patients in the 3F group (p = 0.007). DGER was found in 2 patients (13%) in the 2F group and in 8 (53%) in the 3F group (p = 0.023). Four patients (25%) in the 2F group and 9 (60%) in the 3F group (p = 0.048) had reflux esophagitis. Cervical lymph node dissection increases acid reflux and DGER and can lead to an increase in the incidence of reflux esophagitis in patients undergoing intrathoracic esophagogastrostomy.

Modern Esophageal Function Testing and Gastroesophageal Reflux Disease in Morbidly Obese Patients

BackgroundThe implementation of high-resolution manometry (HRM) and the Lyon Consensus statement facilitate evaluation of gastroesophageal reflux disease and motility disorders in morbidly obese patients. Therefore, we aimed to investigate prevalence and phenotype of (borderline) GERD and esophageal motility disorders in this population.MethodsConsecutive morbidly obese (BMI ≥ 35 kg/m2) patients were offered evaluation by means of HRM, ambulatory 24-h pH impedance monitoring, endoscopy, and a clinical examination at our tertiary academic center. Data were collected prospectively.ResultsOut of 448 eligible individuals, 147 patients (females = 75, 51%) with a median age of 41.6 (33.4; 52.3) years and a BMI of 44 (40.9; 49.4) kg/m2 were included during the study period. The Chicago Classification revealed motility disorders in 50 (34%) patients, dominated by outflow obstruction (18.4%, n = 27) and a novel disorder (7.5%, n = 11), nicknamed jackhammer esophagus (JE). According to the Lyon Consensus, 52 (35.4%) patients had evidence of true GERD, whereas borderline GERD was noted in another 60 (40.8%). Hypersensitive esophagus was observed in 6.8% (n = 10). Sensitivity and specificity of symptoms for GERD were 53.8% and 68.4%, respectively.ConclusionsThe current gold standard of assessment revealed that the prevalence of esophageal motility disorders and (borderline) GERD is high in the morbidly obese population. Further longitudinal data are needed to delineate the natural course of novel motility disorders like JE in obesity and to identify risk factors for adverse outcomes following bariatric surgery.

Anti-reflux mucosectomy using a cap-assisted endoscopic mucosal resection method for refractory gastroesophageal disease: a prospective feasibility study

Endoscopic therapy of gastroesophageal reflux disease (GERD) overcomes the "treatment gap" for patients with refractory GERD, who are not willing to go into surgery. We propose an easy and efficient technique that is referred to as anti-reflux mucosectomy (ARMS) using cap-assisted endoscopic mucosal resection (EMR-C) which could be called ARMS-C. This study aimed to investigate the short-term outcomes of ARMS-C in GERD patients. From December 2016 to February 2018, we performed ARMS-C in 33 patients with pathologic reflux disease and esophageal hypersensitivity. ARMS-C involved endoscopic mucosal resection at the circumference of the esophagogastric junction (EGJ), resulting in narrowing of the hiatal opening after healing. The GERD symptoms, 24-h pH monitoring results, manometry, endoscopy, and EGJ distensibility were compared before and after the procedure. Six months after ARMS-C, 63% of patients discontinued the use of pump inhibitors (PPIs), while 30% patients reduced their PPI dose. The GERD questionnaire scores significantly decreased after ARMS-C, from 11.0 to 6.0 (P < 0.001). The median DeMeester score and acid exposure time based on pH monitoring also improved after ARMS-C. Furthermore, the median flap valve grade and EGJ distensibility decreased from 3.0 to 1.0 (P < 0.001) and from 19.0 to 13.9 (P < 0.001), respectively. Two patients were treated with balloon dilation due to stricture, but no other serious adverse events were encountered. ARMS-C may be an effective and safe treatment method for GERD in terms of short-term outcomes.

Assessment of conservative dietary management as a method for normalization of 24-h urine pH in stone formers.

Low urine pH is a metabolic risk factor for stone formation. While medical therapy is typically prescribed (as urinary alkalinization), patients typically prefer dietary modifications. We aimed to assess capacity to alter urine pH with dietary management alone. We analyzed a retrospective cohort of stone formers seen between 2000 and 2015 with multiple 24-h urine collections (24hUC). Patients ≥ 18years old with low urine pH (< 6.0) were included; those prescribed alkalinizing agents or thiazides were excluded. Demographic data, 24hUC parameters, and medications were abstracted. 24hUC was utilized to calculate gastrointestinal alkali absorption (GIAA). The primary outcome was urine pH ≥ 6.0 on second 24hUC. Predictors were selected utilizing multivariable logistic regression. The database consisted of 2197 stone formers; 224 of these met inclusion criteria. On second 24hUC, 124 (55.4%) achieved a favorable pH ≥ 6.0. On univariable analysis, a second pH ≥ 6.0 was associated with high initial pH, low initial sulfate, younger age, increase in citrate/GIAA/urine volume, and decrease in ammonium (P < 0.02). On multivariable analysis, high initial pH (OR = 23.64, P < 0.001), high initial GIAA (OR = 1.03, P = 0.001), lower initial sulfate (OR = 0.95, P < 0.001), increase in urine volume (OR = 2.19, P = 0.001), increase in GIAA (OR = 8.6, P < 0.001), increase in citrate (OR = 2.7, P = 0.014), decrease in ammonium (OR = 0.18, P < 0.001), and younger age (OR = 0.97, P = 0.025) were associated with a second pH ≥ 6.0. The analysis demonstrated a corrected AUC of 0.853. These data suggest that certain dietary recommendations (increases in urine volume, citrate, GIAA, and decreased acid load) may normalize urine pH in a select group of patients. This may allow urologists to counsel patients with low urine pH on possibility of success with dietary modification alone.

Increased body fatness adversely relates to 24-hour urine pH during childhood and adolescence: evidence of an adipo-renal axis

Reduced net acid excretion (NAE) capacity indicates a decrease in renal function. This reduction manifests as a disproportionally low 24-h urine pH in relation to the sum of actually excreted ammonium and titratable acidity by the kidney. The aim of this study was to test the hypothesis that higher body fatness is one determinant of kidney function impairment with a lowered urine pH even at a young age. NAE, pH, urea, and creatinine were measured in 24-h urine samples from 524 healthy children and adolescents (aged 6-17 y) participating in the DOrtmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study. Body fatness was assessed anthropometrically by body mass index-standard deviation score (BMI-SDS), fat mass index (FMI), body fat % (BF%), and waist circumference (WC). Multivariable linear and mixed linear regressions were used to examine cross-sectionally (n=524 urine samples; age groups: 6-8, 9-11, 12-14, 15-17 y) and longitudinally (n=1999 urine samples) the associations of body fatness with 24-h urine pH as the outcome variable, respectively. After adjusting for the kidneys' total net acid load (24-h urinary NAE) and further relevant covariates, FMI showed significant inverse relations with urinary pH in all 4 age groups, and BMI-SDS, BF%, and WC each in 3 out of these 4 groups (P≤0.02). Longitudinal results substantiated these interindividual relations and further showed intraindividual increases in body fatness to be paralleled by urine pH decreases (P≤0.0002). Independent of underlying acid load, an early increase in body fatness is associated with increased free proton excretion, and thus with a decline in the kidney's acid excretion function, which could potentiate the risk of renal nephrolithiasis.

Diagnosis of laryngopharyngeal reflux in children with voice disorders using 24-hour pharyngeal pH monitoring

ObjectivesThe aim of this study was to assess the usefulness of 24-h pharyngeal pH monitoring in the diagnosis of laryngopharyngeal reflux (LPR) in children with voice disorders. MethodsThe study was conducted on 68 children aged 3–18 years old. In all cases, pH monitoring was successful; no child removed the probe from the nasal cavity or reported discomfort or other complaints. The following definitions were adopted: LPR in the upright position if Ryan Score upright >9.41; LPR in the supine position if there was at least one supine episode below pH 5.0 (equal to a Ryan Score supine >2.91). ResultsIn 43 children (63%), vocal fold edema was strongly related to recorded reflux episodes, especially in the upright position. In 18 children (26%), vocal nodules were observed, but their occurrence did not significantly affect the Ryan Score, either upright or supine. The selected potential LPR markers were significantly correlated to all the pH monitoring variables and individual elements on the Reflux Symptoms Index and the Reflux Finding Score questionnaire. ConclusionOur findings indicate that, together with vocal fold edema, laryngeal edema and posterior commissure mucosal hypertrophy are important determinants of paediatric LPR. In fact, if LPR is suspected in a child, 24-h pharyngeal pH monitoring appears to be a valuable and welltolerated diagnostic tool. Vocal fold edema observed in laryngeal endoscopy can be considered a probable sign of LPR. The Reflux Finding Score appears to be helpful in diagnosing LPR in children, especially if a cut-off value of 4/5 is adopted.

Outcomes of laparoscopic sleeve gastrectomy by means of esophageal manometry and pH-metry, before and after surgery.

IntroductionGastroesophageal reflux is a major problem after sleeve gastrectomy. There is still insufficient understanding of how it occurs and whether it is due to the sphincter length, relaxation, or pressure differences.AimThis study evaluates the effect on the lower esophageal sphincter of the laparoscopic sleeve gastrectomy (LSG) technique applied in surgery in cases of morbid obesity using ambulatory 24-h pH monitoring (APM) and esophageal manometry (EM).Material and methodsA retrospective examination was carried out on the APM and EM tests performed preoperatively and postoperatively in cases of LSG. The parameters examined were the body mass index (BMI), amplitude pressure of the esophagus (AP), total length of the lower esophageal segment (LESL), resting pressure of the LES (LESP), residual pressure of the LES (LESR), relaxation time of the LES, intragastric pressure, and the DeMeester score.ResultsA total of 62 cases with available data were evaluated. A statistically significant difference was determined between the preoperative values and the 3-month postoperative values of BMI, LESP, and relaxation time of the LES. A statistically significant increase was determined in the DeMeester score, and the increase in the total number of reflux episodes longer than 5 min was found to be the most responsible for this increase. No significant difference was determined in the other parameters.ConclusionsThe LSG was found to cause a reduction in LESP, and an increase in acid reflux causing an extended relaxation time of the LES. This was confirmed by the increase seen in the DeMeester score.

Validation of new Japanese classification system for esophageal achalasia

BackgroundThe fourth edition of New Japanese classification system for esophageal achalasia was revised after a long interval of 30 years in 2012. In this new system, achalasia is morphologically classified into 3 types, based on its X-ray findings. However, the system has been limitedly used in Japan and has not been fully validated in terms of its predictive capability of postoperative outcomes. The purpose of this study was to clarify the validity of new Japanese classification system for esophageal achalasia, as an index of patient characteristics and as a predictor of operative and mid/long-term postoperative outcomes.Patients and methodsFifty-nine cases of achalasia underwent laparoscopic Heller–Dor surgery between 2005 and 2018. We evaluated retrospectively patient characteristics, intraoperative findings, esophageal manometry, 24-h pH monitoring and postoperative course.ResultsThere were 34 St and 25 Sg/aSg cases. Age of St group was lower than Sg group. Preoperative duration of disease of St group was shorter than Sg. There were no differences in the results of surgical outcomes and prognoses.ConclusionThe new Japanese classification system may give additional insight and information in understanding epidemiology of esophageal achalasia; however, our study failed to demonstrate “inter-disease type” differences in surgical outcomes and prognoses.